Healthcare Provider Details

I. General information

NPI: 1790635415
Provider Name (Legal Business Name): CENTER OF AESTHETIC AND RECONSTRUCTIVE SURGERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36800 WOODWARD AVE STE 112
BLOOMFIELD HILLS MI
48304-0916
US

IV. Provider business mailing address

125 BRIDGEVIEW DR
BLOOMFIELD HILLS MI
48304-2425
US

V. Phone/Fax

Practice location:
  • Phone: 248-890-2515
  • Fax:
Mailing address:
  • Phone: 248-890-2515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KONGKRIT CHAIYASATE
Title or Position: PRESIDENT
Credential: MD
Phone: 248-890-2515